IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 28th day of December, 2022
Present: Sri.Manulal.V.S, President
Sri.K.M. Anto, Member
CC No. 06/2021 (Filed on 13/01/2021)
Complainants : 1. Sreelatha P.R, W/o Baburaj
56 years, Punnakkal House
Kunnappilly, Peruva P.O
Kottayam-686610.
2. Baburaj, S/o Rajappan Nair
60 years, Punnakkal House
Kunnappilly, Peruva P.O
Kottayam-686610, Mob-9596264389
(Adv.T.R.Sathian)
Vs
Opposite party : M/S Cholamandalam MS
General Insurance Company Ltd
Acel Estate, Iyyattil Junction
Chittoor Road, Cochin -682011
Represented by the Branch Manager.
(Adv.Agi Joseph)
O R D E R
Sri.Manulal.V.S, President
The Complaint is filed under section 12 of the Consumer Protection Act1986.
Case of the complainant is as follows:
The complainants are husband and wife. As induced bythe authorized agent of the opposite party the firstcomplainant joined in the Group Health Master policy ofthe opposite party issued in the name of the CentralBank of India. The representative of the opposite partywas convinced the health condition of the insured as well ashis family members before the issuance of the insurancepolicy. The agent informed the complainant that nomedical checkup is necessary since he was convinced ofthe health conditions of the insured and her familymembers. The type of the policy was Family Floater andthe total sum assured was Rs.3,00,000/- the period ofthe policy was from 27-03-2019 to 28-03-2020. The totalannual premium amounts including GST was Rs.7,866/-instead of that the representative of the opposite partycollected Rs.8,500/-.
On 12-09-2018, the second petitioner felt some burningsensation to his chest and also chest discomfort, hevisited the Vigy Medical Center Piravam and there ECGvariation was detected, and they instructed thecomplainants to undergo better treatment. Accordingly,the second petitioner was taken to Caritas hospital andthe doctor advised an immediate angiogram. After theangiogram, the second complainant was admitted in thehospital and the Bypass surgery was held on 17-09-2019and discharged on 25-09-2019.
The first complainant paid Rs.3,32,747/- for the treatmentof the second complainant. Though a claim was lodgedto the opposite party on 14-10-2019 along with relevantdocuments after several months it was informed thatthe claim would not be payable, as it was the first yearof the policy. Such information and contingency werenot given by the representative at the time of taking andissuing the policy. The complainant approached theInsurance Ombudsman for the Redressal of theirgrievances. The Hon’ble Insurance Ombudsmandismissed the complaint.
It is averred in the complaint that the complainants hadnot suppressed any material facts relating to ailments ormedication for anybody among them. The casesummary never reported that the complaint ofhypertension of the second complainant, was persistingand is undergoing any continuous and prolongedtreatment to him, towards alleged hypertension and fitscaused to him before 20 years. It is not correct to saythat the second petitioner had a Cerebro VascularAccident before 20 years. The repudiation of the claimby raising imaginary stories and also based on theassumption and presumptions amount to a deficiency inservice on the part of the opposite parties. Hence thiscomplaint has been filed by the complainant praying foran order to pay Rs.3,00,000/- with interest from 14-10-2029 till realization along with a compensation of Rs.1,00,000/- and Rs.25,000/- as cost of this litigation.
Upon notice opposite party appeared and filed versionas follows:
The subject claim was made under policy no.2876/00006637/000003/000/00 under the group healthinsurance policy issued in the name of the complainantwho is the account holder of Central Bank of India forthe period from 27-03-2019 to 26-03-2020 for a total sumassured of Rs.3,00,000/-. The claimant’s husband wasadmitted to Caritas hospital from 12-09-2019 to 25-09-2019 for Triple Vessel Coronary Artery Disease/moderate to severe LV dysfunction. The dischargesummary revealed type II DM and systemichypertension. The opposite party has investigated the said claim through an outsourcing agency and theysubmitted the investigation report along with the casesheet of the patient from Caritas hospital. It is clearfrom the case sheet that Baburaj was suffering fromhypertension since 20 years and CVA 20 years back ontreatment-Eptoin.
The present ailment is a complication attributable toHypertension which was existing for 20 years which isprior to the inception of the policy. Hence, the presentailment is considered a pre-existing disease and theclaim is inadmissible under general exclusion clause 3.2.The complainant had taken the policy by concealingmaterial facts which is a violation of policy conditions.There is no deficiency in service on the part of theopposite party.
The complainant filed proof affidavit in lieu of chiefexamination and marked exhibits A1 to A5 from the sideof the complainant. Manjusha v who is the DeputyManager claims of the opposite party filed proofaffidavit in lieu of chief examination and exhibit B1 to B8were marked.
On the evaluation of the complaint version and evidenceon record, we would like to consider the followingpoints.
1. Whether there is any deficiency in service or unfairtrade practice on the part of the opposite parties?
2. If so what are the reliefs and costs?
Point number 1 and 2
There is no dispute on the fact that the complainants availed the policy vide policy no.2876/00006637/000003/000/00 under the group health insurance policy issued in the name of the complainant who is the account holder of Central Bank of India for the period from 27-03-2019 to 26-03-2020 for a total sum assured of Rs.3,00,000/-. It is proved by Exhibit B2discharge summary that the second complainant was admitted to Caritas hospital from 12-09-2019 to 25-09-2019 for Triple Vessel Coronary Artery Disease and the Bypass surgery was held on 17-09-2019. Though the claim form was submitted by the complainants the same was repudiated by the opposite party on the ground that ailment is a complication attributable to Hypertension which was existing since 20 years which is prior to the inception of the policy.
It is contended by the opposite party that the complainant had taken the policy by concealing material facts which is a violation of policy conditions. The opposite party relied upon clause 3.2 of the policy conditions. As per clause 3.2 of the policy conditions benefits will not be available for any pre-existing condition (s) as defined in the policy until 24 consecutive months of continuous coverage have elapsed, since the inception of the first policy.
On perusal of exhibit B2 discharge summary, we cannot see any history of the pre-existing disease to the complainant. On perusal of exhibit B2, we can see that Type II DM, systemic hypertension, and Seizure disorder is diagnosed at Caritas hospital. Exhibit B5 is the photocopy of the case sheet of the second complainant.
On perusal of exhibit B5, we can see that it was recorded in the past no cardiac column as CVA neurologic 20 years back. In present history, it was recorded as diabetic and hypertension. In RP No. 4461 of 2012, Neelam Chopra Vs. Life Insurance Corporation of India; Ors., decided on08.10.2018, (NC), it was held that:11. From the above, it is clear that the insurance claim cannot be denied on the ground of these lifestyle diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.
Moreover, the non-disclosure of information in respect of this lifestyle disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Honourable High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra);The Honourable National Commission while dealing with a similar set of facts, in Sunil Kumar Sharma Vs. TATA AIGLife Insurance Company and Ors. bearing case no. RP no.3557/2013 decided on 01.03.2021 held as under:-
Moreover the claim had been repudiated only onthe ground that the insured was suffering from diabetesfor a long time. So far as lifestyle diseases like diabetesand high blood pressure are concerned, the HonourableHigh Court of Delhi in Hari Om Agarwal Vs. OrientalInsurance Co. Ltd., W.P.(C) No. 656 of 2007, decided on17.09.2007 held as under;Insurance-Mediclaim-Reimbursement-Present Petitionfiled for appropriate directions to respondent toreimburse expenses incurred by him for his medicaltreatment, in accordance with the policy of insurance-Held, there is no dispute that diabetes was a conditionat the time of submission of the proposal, so washypertension-Petitioner was advised to undergo ECG, which he did-Insurer accepted the proposal and issued cover note-It isuniversally known that hypertension and diabetes canlead to a host of ailments, such as stroke, cardiacdisease, renal failure, liver complications dependingupon varied factors-That implies that there is aprobability of such ailments, equally, they can arise innon-diabetics or those without hypertension. It would beapparent that giving a textual effect to Clause 4.1 ofpolicy would in most such cases render mediclaim covermeaningless-Policy would be reduced to a contract withno content, in event of happening of contingency-Therefore Clause 4.1 of policy cannot be allowed tooverride insurer primary liability-Main purpose rulewould have to be pressed into service-Insurer renewedpolicy after petitioner underwent CABG procedure-Therefore refusal by the insurer to process andreimburse the petitioner’s claim is arbitrary andunreasonable-As a state agency, it has to set standardsof model behaviour; its attitude here has displayed acontrary tendency-Therefore direction issued to therespondent to process the petitioner’s claim, and ensurethat he is reimbursed for procedure undergone by himaccording to claim lodged with it, within six weeksand petition allowed.Satish Chander Madan v. Bajaj Allianz GeneralInsurance, 2016 SCC Online NCDRC 28, decided on 11January 2016NCDRC, after perusing the relevant records and hearingthe parties, observed that “the only fact established bythe above reports (medical report of the petitioner) isthat the petitioner prior to obtaining insurance policywas having history of hypertension. This, however, doesnot lead to the conclusion that the petitioner was alsohaving previous history of heart problems. Therefore,the insurance claim submitted by the complainant fortreatment of his heart problem cannot be termed as aclaim in respect of a pre-existing disease. Thus,repudiation of insurance claim by the respondentopposite party is not justified.” “Hypertension is acommon ailment and it can be controlled by medicationand it is not necessary that a person suffering fromhypertension would always suffer a heart attack.Therefore, the argument advanced by the respondent isfar-fetched and is liable to be rejected,” noted theCommission while allowing the revision petition andrestoring the order of the District Forum.
The fact that the petitioner suffered from cardioincident within six months of taking the Policy can bejust a coincidence and cannot be held to be sufficient toannul the Policy. Similarly, the petitioner’s disclosure ofhim having suffered from CVA neurologic 20 years backto the doctors at the time of his admission to thehospital, may also be because the doctors at thehospital may have put this specific query to him.Anyway, it cannot be inferred from this that thepetitioner was aware that the disclosure of thisinformation in the Proposal Form was material.In view of the above discussion, it must be held that therepudiation of the Policy by the opposite party and theconsequent rejection of the claim of the petitionerthereunder, was unreasonable and could not have beensustained.
Therefore we are of the opinion that the oppositeparties have committed deficiency in service byrepudiating the genuine claim of the secondcomplainant and thereby caused much mental agonyand hardship to the complainants. Exhibit b7 claimcomputation sheet proves that the complainants claimed an amount of Rs.3,30,748/- as the treatmentexpenses of the second complainant. Admittedly the sum assured was Rs.3,00,000/ and the opposite party is not liable to pay any amount excess than the insuredsum. Considering the nature and circumstances of thecase we allow the complaint and pass the followingorder.
We hereby direct the opposite party to pay Rs.3,00,000/- which is the sum assured to complainants within 30 daysfrom the date of receipt of this order.
We hereby direct the opposite parties to payRs.25,000/- as compensation for the deficiency in servicecommitted by the opposite party and Rs.5,000/- as thecost of this litigation.The order shall be complied with within 30 days from the date of receipt of copy of this order in defaultawarded amount will carry 9%from the date of this order till realization.
Pronounced in the Open Commission on this the 28th day of December,2022.
Sri.Manulal.V.S, President sd/-
Sri. K.M. Anto, Member sd/-
Appendix
Exhibits marked from the side of complainant
A1- Claim form submitted by the petitioners.
A2- Covering letter dated 18/08/2020, from the office of the Ombudsman.
A3- Medical certificate dated 20/11/2019 from Dr.Vinitha V Nair.
A4- Copy of the letter dated nil, issued by Dr.Vinitha V Nair, to the opposite party.
A5- Copy of the award passed by the Insurance Ombudsman.
Exhibits marked from the side of opposite party
B1- Copy of terms and conditions of the Group of Health Insurance Policy
B2- Discharge summary of 2nd petitioner issued by Caritas Hospital, Thellakom.
B3- Copy of claim form.
B4- Copy of investigation report.
B5- Copy of case sheet issued from Caritas Hospital.
B6- Letter dated 24/01/2020 from Cholamandalam MS General Insurance Company Ltd.
B7- Copy of computation sheet.
B8- Copy of Insurance Ombudsman proceedings.
By Order
Sd/-
Assistant Registrar
